The value of radiosynoviorthesis for treatment of chronic synovitis in hemophilic joint disease

Chronic synovitis is contributing to the development of arthropathy in hemophilia A and B. In most patients with severe and moderate hemophilia, during lifetime, joint damage progresses despite early prophylaxis and intense treatment with coagulation factor concentrates. Recurrent hemorrhages into the joints and subclinical bleeding lead to chronic inflammation of the synovium, neoangiogenesis and remodeling, sustaining a vicious circle of bleeding-remodeling-bleeding and progression of osteochondral damage. Imaging techniques including ultrasound and MRI are able to early visualize synovitis and osteochondral changes. Early detection and sustained therapy of synovitis are important preconditions to prevent further deterioration of joint status. Chronic synovitis requires intensified substitution of coagulation factors and concomitant analgetic, antiphlogistic and physical therapy. The value of early radiosynoviorthesis (RSO) as effective method to control ongoing synovitis is discussed here. RSO is recommended as first choice therapy in case of persistant chronic synovitis, recorded in both national and international guidelines.

Use of radiosynovectomy in recurrent warfarin-related haemarthrosis in degenerative arthritis

Radiosynovectomy is a local and minimally invasive radiotherapy for treating various chronic inflammatory arthritis such as rheumatoid arthritis, osteoarthritis and haemophilic arthropathy. In haemophilic arthropathy, it reduces the frequency of haemarthrosis and delays the development of severe joint destruction, which ultimately requires surgical intervention. Its role in warfarin-related haemarthrosis is less clear. Haemarthrosis is an uncommon complication of warfarin use, and anticoagulation may need to be discontinued. We describe yttrium-90 radiosynovectomy use in a 74-year-old man with underlying ischaemic heart disease, atrial fibrillation, previous embolic stroke and recurrent haemarthrosis of an osteoarthritic right knee. Anticoagulation was vital and could not be permanently stopped. Due to continuing anticoagulation, he had multiple hospitalisations with recurrent right knee haemarthrosis. Intraarticular right knee yttrium-90 citrate colloid injection led to a cessation of haemarthrosis for eight months. We examined the available literature for the role of radiosynovectomy in such circumstances.

A long term results of external beam radiation therapy in hemophilic arthropathy of the ankle in children

Bleeding into joint space is critical to develop hemophilic arthropathy. To reduce the frequency of bleeding in the ankle joint of children with hemophilic arthropathy, low dose external beam irradiation was performed for 37 patients. Among them, 35 patients followed-up for longer than 1 yr (median 87 months) were enrolled for analysis. The average number of bleedings per month was 3.6 during one year prior to radiation therapy. After radiation therapy, it was decreased to 2.1 during the first year, after then it was maintained in the range of 1.0 to 1.5 until the tenth year. The bleeding frequency was reduced to 42% at the first year and it was maintained in the range of 58% to 73% from the second to the tenth year. Especially the patients who had 3 or more bleedings per month, and who had MRI score more than 3 showed significant decreases. During the follow-up period, growth disturbances and secondary malignancies were not found. External beam radiotherapy can be considered for the hemophilic patients with surgical or isotope therapies are not amenable.

Radiosynoviorthesis in children with haemophilia

Recurrent bleeding into joints represents the clinical hallmark of haemophilia and, if not adequately treated, it may cause chronic synovitis and degenerative arthropathy. The first treatment option of recurrent haemarthroses and/or chronic synovitis is represented by synoviorthesis, both chemical and radioisotopic, with a success rate of approximately 80% for both. However, radioisotopic synoviorthesis should be preferred because it makes it possible to obtain complete synovial fibrosis usually in one session, without the need for repeated injections, thus reducing the risk of bleeding complications and concentrate consumption. For all these reasons this procedure should be implemented and supported, particularly in developing countries.

[The synoviorthesis: a reappraisal]

BACKGROUND

The evolution of the rheumatologic practice involved a handing-over in question of the place and methods of application of the synoviorthesis. The last innovations, in particular the appearance of the bio-therapies, allowed a better control of inflammatory rheumatism thus making it possible to better select arthritis likely to profit precociously from a synoviorthesis before the installation of major articular destruction.

AIM

Through a general review of the literature, we recall in this work the various means of synoviorthesis, their current indications and their results.

METHODS

An extensive electronic search of the relevant literature was carried out using MEDLINE. Key words used for the final search were: synoviorthesis, osmic acid, radiosynoviorthesis, arthritis, treatment.

RESULTS

This systematic review allowed us to conclude that fields of application of the synoviorthesis is in addition widens because of the interesting results to see spectacular this technique in some other affections such as the haemophilia. In addition we have compared the efficiency and the tolerance of the different methods of synoviorthesis.

CONCLUSION

The synoviorthesis constitutes a tempting therapeutic alternative of share its effectiveness and its good tolerance so much so that it constitutes an undeniable factor of articular protection. Its fields of application widened. Thus on the good knowledge of the indications and the precautions necessary to its realization its success.

Rhenium-186 Hydroxyethylidenediphosphonate (186Re HEDP) for the Treatment of Hemophilic Arthropathy

OBJECTIVES

The aim of this study was to evaluate the efficacy of a systemic application of rhenium-186 hydroxyethylidenediphosphonate (Re HEDP) for pain treatment in patients with hemophilic arthropathies.

METHODS

Twelve patients with hemophilic arthropathy with at least 3 involved joints with persistent pain were included in this prospective study. A single dose of 15 mCi (555 MBq) Re HEDP was administered intravenously. Before and 12 weeks after treatment, pain assessment was performed using the visual analog scale (VAS). The pain status assessment included the general status, pain of all joints affected, and pain of the 3 mostly involved joints. Furthermore, quality of life was assessed.

RESULTS

With regard to the 3 most involved joints, an improvement of the pain symptoms in 25 of 36 (69.4%) joints was observed. With regard to all involved joints a median of 3 joints per patient improved after Re HEDP therapy. General pain status after treatment was 2.0 VAS points lower as compared with pretreatment. The total number of involved joints remained unchanged in 7 patients, increased in 1 patient, and decreased in the remaining 4 patients.

CONCLUSIONS

The results of this study show an improvement of the pain symptoms of the involved joints 12 weeks after therapy with Re HEDP in patients with hemophilic arthropathy. The only moderate success regarding a reduction of the total number of involved joints is by the fact that despite this improvement most affected joints remained still painful on a lower level after the therapy or due to newly affected joints not painful before initiation of the radionuclide therapy.

(32)P colloid radiosynovectomy in treatment of chronic haemophilic synovitis: Iran experience

Repeated intra-articular bleeding with subsequent development of chronic synovitis and cartilage changes, leading to haemophilic arthropathy, is one the most debilitating problems in haemophilic patients. Radiosynovectomy is a familiar therapeutic choice in management of chronic synovitis in haemophilia. We report the treatments results of synoviorthesis with (32)P chromic phosphate with emphasis on clinical aspects. Between 2002 and 2006 we performed 66 procedures in 53 patients. Seven patients were excluded. The remaining 46 patients were followed for an average of 31 months. The mean age of patients at the time of injection was 15.9 years (range: 6-28). There were three repeat injections. According to Fernandez-pallazi and Cavilgia clinical classification (Table 1) [23], nine joints were Stage II and 46 were Stage III. In latest follow-up, 77% of patients reported at least a 50% decrease in bleeding frequency after treatment (P < 0.0001). The need for antihaemophilic factor consumption dropped by about 74% postradiosynovectomy (P < 0.0001). In most of the injected joints, the range of motion remained stable or improved. A trend was found for the number of haemarthrosis to increase after a period of considerable improvement. Synoviorthesis using (32)P effectively reduces the intra-articular bleeding rate and factor concentrate use. Durability of the response seems to be unpredictable, perhaps attributable to the late intervention. An early radiosynovectomy might be more helpful in terms of stability of response to treatment.

Radiosynoviorthesis of medium-sized joints with rhenium-186-sulphide colloid: a review of the literature

Hypertrophy and inflammation of the synovium with various underlying pathologies - such as rheumatoid arthritis, osteoarthritis, haemophilia and spondyloarthropathy - can be treated successfully by radiosynoviorthesis (RSO). For medium-sized joints (shoulder, elbow, wrist, hip and ankle), the radionuclide of choice is rhenium-186. We review the evidence for the efficacy of this local, relatively non-invasive therapy and evaluate its benefits and risks. We conclude good evidence of rhenium-186 RSO in rheumatoid arthritis and haemophilic arthropathy. In the remaining pathologies, up to now, the therapeutic efficacy has not been confirmed by today's most stringent criteria for clinical studies. The available data support rhenium-186 RSO as a suitable second-line treatment for patients in whom other therapies (including locally injected corticoids) have failed, as long as proper attention is paid to correct administration - including post-treatment immobilization and the co-administration of corticoids.

Radiosynoviorthesis for treatment of hemophilic hemarthrosis--Slovenian experience

Radiosynoviorthesis is a well-accepted method for the treatment of recurrent hemarthrosis in hemophilic patients.

OBJECTIVES

The aims of our study were to evaluate the effectiveness of radiosynoviorthesis in patients suffering from hemophilic hemarthrosis, to determine the effect of treatment on antihemophilic factor consumption, and to assess the patient's satisfaction with radiosynoviorthesis.

METHODS

Between 2001 and 2003, 26 radiosynoviortheses were done in 21 hemophilic patients; in 4 patients the treatment was repeated, and in 1 patient two joints were treated. 90Y colloid was used for the knee joint, and 186Re colloid was used for ankle, shoulder, and elbow radiosynoviorthesis.

RESULTS

The bleeding frequency decreased by at least 50% in 53% of patients in the year after radiosynoviorthesis, as compared to the year prior to the therapy. Considering only those patients who had at least 12 bleedings into the treated joints in the year preceding the therapy, the bleeding frequency decreased by at least 50% in 62% of these patients. In this group, the consumption of the antihemophilic factor was notably reduced (on average, by 25,800 I.U./year). All patients reported that the treated joint was much better or better than before the radiosynoviorthesis.

CONCLUSION

Radiosynoviorthesis is an effective method for the treatment of hemophilic hemarthrosis, particularly in patients with frequent intra-articular bleedings. The antihemophilic factor consumption was markedly reduced only in patients with frequent joint bleeding. Radiosynoviorthesis is well accepted by patients suffering from hemophilic hemarthrosis.

Radiation synovectomy by 188Re-Sulfide in haemophilic synovitis

Radiation synovectomy is a safe and effective treatment for chronic haemophilic synovitis causing recurrent haemarthroses. This study reports results of 29 188Re-sulfide radiation synovectomies in knee joint with a follow-up 18 months. Using the absorbed dose factor, three groups of radioactivity dose (555 MBq, 687 MBq and 917 MBq) were used according to the synovium thickness that measured by MRI. Excellent and good results (haemarthrosis reduction from 75 to 100%) were obtained in 71% of cases at 18 months. Comparison of the results, no significant difference was found among the radioactivity dose groups. Radiation was well contained within the knee. There were no observed or identified complications including the detectable harm to the articular cartilage, as shown by MRI.

Yttrium synoviorthesis of the elbow joints in persons with haemophilia

Yttrium has been used as the material of choice for synoviorthesis in our centre since 1984. An audit was carried out to determine the long-term results of this modality for treating elbow joints. An unacceptably high percentage of patients lost range-of-movements in the articulation treated. Good results were achieved with respect to a reduction in the bleeding incidences. It is suggested that another isotope be utilized and that other centres carry out an audit and publish their data.

[Quantification of bone scintigraphy as an objective method in the follow-up of radioisotopic synoviorthesis]

This work tries to provide the clinicians an objective tool that can contribute to the assessment of the results of radioisotopic synoviorthesis (RS). This study aims to assess the value of the quantification of bone scintigraphy in blood pool and late phase of the affected joints treated with 90Y silicate, in order to observe the clinical improvement experienced by most of these patients. A total of 69 bone scintigraphies (BS) in blood pool and late phase have been quantified. They belonged to 23 patients who were treated with RS with 90Y. The first scintigraphy study was performed before the treatment, the second and the third ones were performed 2 and 6 months after treatment. In each BS we quantified the index: counts per pixel of healthy / affected joint. We also have calculated the fraction in the late phase: counts per pixel of healthy bone / counts per pixel of affected and healthy joint. For the comparative statistical analysis of the results we used the Student's t test. We considered statistical significance when p < 0.05. All the patients presented clinical improvement. If we compare the index obtained in BS 2 months after treatment and pre-treatment we find statistical significance (p < 0.05) in the increase of index in the anterior view and late phase. If we compare the index obtained in BS 6 month after treatment and pre-treatment, we find a statistically significant increase in the anterior (p < 0.01) and posterior (p < 0.05) view of the blood pool phase and the anterior view of late phase (p < 0.01). The fraction counts per pixel of healthy bone / counts per pixel of affected and healthy joint did not present a significant increase in any BS control (2 and 6 months). We recommend quantification using the index (counts per pixel healthy / affected joint ) proposed in this work, because it is easy to perform, cheap and reliable in the follow-up of patients treated with RS.

Late clinical, plain X-ray and magnetic resonance imaging findings in haemophilic joints treated with radiosynoviorthesis

The clinical, plain X-ray and magnetic resonance imaging (MRI) findings were studied in 13 haemophilic joints previously treated with radiosynoviorthesis. (32)P had been injected into the joints at a median of 16 years earlier in an attempt to halt recurrent haemorrhage. Prior to (32)P injection, the majority of joints demonstrated bone damage evident on plain X-ray, secondary to recurrent haemorrhage. At the follow-up evaluation we found plain X-rays were adequate to identify cysts, erosions and cartilage loss in these very damaged joints. MRI was superior to clinical examination and plain X-ray in identifying synovial hyperplasia and effusions.

Isotopic synovectomy with P-32 in paediatric patients with haemophilia

Isotopic synovectomy is being proposed as an option in the treatment of patients with haemophilic arthropathy. We present our experience with 11 paediatric patients who underwent 17, P-32 isotopic synovectomies for chronic haemophilic arthropathy. P-32 was injected into the joint per protocol, approved by the institutional review board. All our patients were male. Nine were factor VIII and two were factor IX deficient. The following joints were treated: ankle (n=10 procedures), elbow (n=5) and knee (n=2). The first procedure was performed on December 1993. None were human immunodeficiency virus positive. Mean age at the first procedure was 10.8 years (range, 5.2-15.2 years). Mean pretreatment joint clinical scores using the World Federation of Hemophilia guidelines for the ankle was 5.5 (SD +/- 2.3), the elbow 4.2 (+/-2.5), and knee 5.5 (+/-3.5); the corresponding post-treatment scores were 2.6 (+/-2.0), 1.4 (+/-0.5) and 2.5 (+/-3.5) respectively. Presynovectomy mean radiological scores using the Pettersson method were: ankle 1.8, elbow 1.8, and knee 1.5. A scoring system used in our centre for evaluating joints using magnetic resonance imaging (MRI) gave the following mean pretreatment scores: ankle 9.5, elbow 8.4, and knee 5.0. A marked decrease (an 80-100% decrease) in bleeding was seen in 13 of 17 procedures, and a moderate decrease (51-79% decrease) in two procedures, accounting for 85% reduction in bleeding into the target joints. The procedure was well tolerated and no untoward side-effects were noted as of May 1999, with a median follow-up of 40 months (range 19-65 months). None had any clinical evidence of cancer. Three patients had their joints retreated [elbow (one), ankle (two)]. These procedures were also well tolerated. In conclusion, in our study, isotopic synovectomy using P-32 appears to be feasible, safe and efficacious in the treatment of haemophilic arthropathy in paediatric patients who have been followed for a median of 40 months. As previously shown, MRI appears to give more detailed information about joint arthropathy than plain radiographs.

MRI findings in haemophilic joints treated with radiosynoviorthesis with development of an MRI scale of joint damage

We hypothesized that magnetic resonance imaging (MRI) scans taken prior to radiosynoviorthesis may be predictive of response to the procedure in persons with haemophilia. Specifically, response would be inversely related to the severity of synovial hyperplasia. Radiosynoviorthesis was administered to 21 joints with recurrent haemorrhage (target joints). A detailed self-report of haemorrhage history, joint evaluation with scoring according to the World Federation of Haemophilia orthopaedic joint and pain scales, plain radiographs, and MRI studies of the joints were performed pre- and post-radiosynoviorthesis. To augment comparison of the MRI findings to those assessed using the Arnold-Hilgartner and Pettersson scales, a provisional MRI scale for evaluation of haemophilic arthropathy was designed. We found the MRI findings prior to the procedure were not predictive of clinical response; independent of the severity of synovial hyperplasia, most joints bled less and showed improvement by the WFH orthopaedic score. There was generally no change in the severity of synovial hyperplasia after the procedure. We conclude that MRI evaluation is not routinely indicated prior to radiosynoviorthesis.

Cytogenetic studies in patients with hemophilic hemarthrosis treated by 198Au, 186Rh, and 90Y radioactive synoviorthesis

This study assesses chromosomal structural changes (CSCs) studied by conventional lymphocyte cultures and banding techniques in 79 hemophilic patients with hemarthrosis treated with radioactive synoviorthesis, 31 hemophilic patients with hemarthrosis not treated by this procedure, and 110 nonhemophilic patients matched by age and sex (control group). In 14 patients treated with 198Au (group A), premalignant CSCs and nonspecific CSCs were found, respectively, in 1.69% and 17.23% of metaphases. The former disappeared, but 1.7% of the nonspecific changes persisted 2 years after injection. In 31 patients treated with 186Rh (group B), CSCs were not found previous to radioactive synoviorthesis but were present as nonspecific changes in 1.25% of metaphases 6 months later; they disappeared 1 year after injection. In 34 patients treated with 90Y (group C), CSCs were not found previous to radioactive synoviorthesis but were present as nonspecific changes in 0.89% of metaphases 6 months later; they disappeared 1 year after injection. Only nonspecific CSCs were found in 0.79% of metaphases in patients not treated with radioactive synoviorthesis (group D). CSCs were not present in control subjects. The authors conclude that in some hemophilic patients with hemarthosis treated with radioactive synoviorthesis using 198Au, 186Rh, or 90Y, reversible premalignant or nonspecific CSCs could be present; nonspecific CSCs may persist in a low proportion of metaphases up to 2 years after injection when 198Au is used as the radioactive agent. Radioactive synoviorthesis seems to be from a cytogenetic point of view a safe alternative for these patients.

Radiation therapy in pseudotumour haemarthrosis

Total or partial deficiency of factor VIII and IX in the coagulation cascade leads to haemophilia. Haemophilia affecting weight-bearing joints gives a 'pseudotumour' or haemarthrosis-like condition. Surgery and cryoprecipitate infusions have been the treatment for this condition. Radiocolloids and radiation therapy have been used with some benefit. One case of ankle pseudotumour which was treated by low-dose external beam radiation is presented here.

Radiosynovectomy's clinical applications and cost effectiveness: a review

It is apparent that from the work of the authors and many others, including the work of Rivard, Sledge, Zuckerman, among others, that radiosynovectomy has an important role to play in providing effective treatment of affected joints associated with rheumatoid arthritis and other forms of arthritis as well as the hemophiliac joint. The treatment offers relief from the effects of recurrent joint effusion with an approximately 60% to 66% favorable response and from recurrent hemarthrosis in the hemophiliac joint with an approximately 75% to 80% favorable response. The impact of providing radiosynovectomy as an alternative to surgical synovectomy is seen, where postoperative side effects such as joint stiffness are avoided, improved quality of life is repeatedly documented, and the cost savings in health care dollars, particularly evident in the hemophiliac joint in this relatively small population, are potentially enormous. With almost two million people in the United States suffering from rheumatoid arthritis, the potential savings in health care dollars is also enormous. As with any use of in vivo radiopharmaceuticals, the potential for radiation-induced damage exists. However, with a 25 plus year record of use, more optimally configured radiopharmaceuticals, and the addition of maneuvers to minimize potential joint leakage, the risk of radiation induced damage appears to be minimal. It appears as though radiosynovectomy is an effective as well as cost-effective alternative to surgical synovectomy and is becoming the procedure of choice particularly in the hemophiliac patient with recurrent hemarthrosis and synovitis who has failed medical therapy. It is also the procedure of choice in patients for whom surgery is contraindicated because of the presence of clotting factor inhibitors.

Radioactive synoviorthesis in hemophilic hemarthrosis: materials, techniques, and dangers

Radioactive synoviorthesis with 198Au, 90Y, 186Re, and 31P would seem to be the treatment of choice for recurrent hemarthroses in hemophilia. The clinical results, obtained by different centers, show a definite diminution of hemarthroses in 88% of cases. The advantages of radioactive synoviorthesis compared with surgical synovectomy are: better results, the requirement of substantially reduced antihemophilic factor, the possibility of performing the procedure on multiple cases concurrently on an ambulatory basis, no interference with articular range of movement, and the low cost of the procedure. In cases of failure, the procedure can be repeated after 6 months, and on as many as 3 occasions. Studies performed on the chromosomal changes that could be attributed to the radioactive material show the disappearance of these alterations a few years after treatment. No physical changes have been found that could be attributed to cytogenic alteration (hematologic or other) in any reported patients.

Synoviorthesis with colloidal 32P chromic phosphate for the treatment of hemophilic arthropathy

Between 1977 and 1992, we performed ninety-two synoviortheses (destruction of synovial tissue by intra-articular injection of a radioactive agent) on forty-eight patients who had a severe congenital disorder of hemostasis and chronic hemophilic synovitis that was resistant to conventional treatment. Colloidal 32P chromic phosphate was injected intra-articularly: 1.0 millicurie for knees and 0.5 millicurie for other joints. The duration of follow-up ranged from one to fifteen years. The frequency and importance of bleeding decreased in most of the patients. The range of motion of half of the joints remained stable or improved and that of the other half continued to decrease. Radiographic scores worsened progressively despite the decreased frequency of hemarthrosis. In most patients, the extra-articular leakage of the radioactive agent was slight. Chromosome breakages were observed almost exclusively in patients who were seropositive for human immunodeficiency virus and in whom the CD4-lymphocyte count was decreased from normal. The patients' level of satisfaction with the results was high.

Yttrium synovectomy in haemophilic arthropathy

Between 1987 and 1991 we performed Yttrium-90 (Y-90) silicate radionuclide synovectomies on 40 joints of 20 haemophiliac patients with haemophilic arthropathy. All were male, their mean age was 31 yr and 15 of the 20 (75%) were HIV antibody positive. The number of joint bleeds and amount of factor (VIII and IX) replacement given in the 6 months pre- and 6 and 12 months post-radionuclide synovectomy was compared. Y-90 silicate synovectomy was shown significantly to reduce both the number of joint bleeds (P < 0.001) and factor usage (P < 0.001) in the 6 months after the procedure, a result maintained up to 12 months. Depot methyl prednisolone was co-administered with Y-90 but thought unlikely to contribute to joint response beyond 6 months. The reduction of joint bleeds and factor usage was even more dramatic in the 6- to 12-month period post-synovectomy although this was not reflected by the P value (P < 0.001). The reduction of joint bleeds and factor consumption post-synovectomy was most obvious in elbow joints, although the other joints as a group showed a significant reduction. Patients who were HIV antibody positive showed considerable improvement up to 12 months post-treatment, both in reduction of joint bleeds and as a consequence factor consumption. This improvement was seen to a lesser extent in the smaller HIV-negative group.

Hemarthrosis and synovitis associated with hemophilia: clinical use of P-32 chromic phosphate synoviorthesis for treatment

PURPOSE

To evaluate the clinical usefulness of phosphorus-32 chromic phosphate synoviorthesis in patients with hemophilia, recurrent hemarthrosis, and synovitis.

MATERIALS AND METHODS

Forty-four P-32 colloid synoviorthesis procedures were performed in 38 patients with these abnormalities. P-32 colloid was injected intramuscularly in a dose of 1.0 mCi (37.0 MBq) in adult knees and 0.5 mCi (18.5 MBq) in adult elbows. A thin-window Geiger-Müller counter was used to survey treated joints, lymph nodes, and liver in order to detect leakage from the joint. Follow-up extended to a maximum of 4 years after treatment.

RESULTS

No evidence of clinically significant leakage was seen. Twenty-two of 28 treatments (78%) with longer than 6 months follow-up were associated with improvement in range of motion and frequency of hemorrhage. Of 15 treatments with longer than 2 years follow-up, 10 (67%) were associated with improvement in range of motion; 12 (80%), with improvement in frequency of hemorrhage; and 12 (80%) with improvement in quality-of-life activities.

CONCLUSION

P-32 colloid synoviorthesis is a clinically useful out-patient procedure in patients with hemophilia, recurrent hemarthrosis, and synovitis in whom hemostatic therapy has failed.

Long term follow up of radiosynovectomy with yttrium-90 silicate in haemophilic haemarthrosis

OBJECTIVES

The aim of this study was to evaluate the long term effect of radiation synovectomy with yttrium-90 silicate in haemophiliac patients with recurrent haemarthrosis.

METHODS

The bleeding frequency and the mobility of the joint were recorded in 16 joints of 14 patients 1 year before radiosynovectomy and during follow up, which ranged from 3 to 6 years. Patients evaluated the effect of their own treatment by completing a questionnaire. Radiographs of the joints were scored by an independent radiologist before treatment.

RESULTS

A satisfactory reduction of the frequency of haemorrhage was achieved in 94% of joints during the first year after treatment and was maintained in 63% until the end of the follow up period. In general there was no decrease in mobility attributable to radiosynovectomy, and the patients' own evaluations agreed with the evaluations based on the frequencies of haemarthrosis in 75%. Patients who had only minor, or no, radiological abnormalities of the joints before treatment showed the best results. One patient developed synovitis as a complication of the radiosynovectomy.

CONCLUSION

Radiosynovectomy is an effective and safe treatment for recurrent haemarthrosis in haemophiliac patients, especially in those who have joints with no or minor radiological damage.

Long term follow up of haemophilic arthropathy treated by Au-198 radiation synovectomy

Intra-articular injection of Au-198 (gold synoviorthesis) has been used in the treatment of repeated haemarthroses of the elbows, knees, or ankles in 64 haemophiliacs. These patients had continued to have joint haemorrhages despite appropriate, episodic, substitutive therapy over a period of more than six months. Follow-up for an average period of 14 years in one knee in 38 male haemophiliacs showed 8 good, 23 fair, and 7 poor results with regard to their joint scores. It is concluded that Au-198 is an effective agent for radiation synovectomy, particularly in the early stages of the disease with minimal radiographic changes. It appears to reduce the incidence of haemarthrosis and to slow the rate of evolution of radiographic changes.

Synoviorthesis in young patients with hemophilia and inhibitory antibodies

In five patients under the age of 15 with hemophilia and inhibitors, due to frequent joint bleedings, 13 joints were treated with synoviorthesis (intra-articular injection of radioactive gold). The patients received high doses of factor VIII/IX for 2-4 days or were treated simultaneously with tolerance induction according to the Malmö protocol. Of the 13 joints treated, a bleeding-free interval of more than 6 months was obtained in nine of which six remained free from bleedings for more than a year. Ease of performance, the limited requirements of pre- and postoperative care, and a definite decrease in the joint bleeding frequency render synoviorthesis well suited for use in hemophiliacs with inhibitors who are otherwise difficult to treat.

Synoviorthesis with colloidal 32P chromic phosphate for hemophilic arthropathy: clinical follow-up

Thirty-one synoviortheses were performed in 22 joints of 14 hemophilic patients (aged 12 to 28 years) with chronic synovitis and for whom "conventional treatments" were considered ineffective. Except for patients with inhibitors, conventional treatments included three to six months of adequate prophylactic therapy with the missing coagulation factors, intensive physiotherapy and, when indicated, antiinflammatory agents and orthosis. Colloidal 32P chromic phosphate was injected intraarticularly in doses of 1.0 mCi for knees and of 0.5 mCi for the other joints. Time of follow-up ranged from two to five years. Frequency and importance of bleeding decreased in all patients. Effect on range of motion was best in knees; six of the seven treated improved and one was unchanged. In elbows, flexion-extension was improved in four cases, unchanged in five and decreased in one; pronation-supination was decreased in four cases. Range of motion was not affected in shoulders and ankles except for internal-external rotation which was improved in two of three shoulders treated. The results of 13 synoviortheses in four hemophilic patients with high titer factor VIII inhibitors were comparable to those in hemophiliacs with no inhibitors. However, in three of the four patients synoviorthesis had to be repeated after two to four years for recurrence of synovitis. Extraarticular escape of radioactivity was monitored 62 times for 17 synoviortheses in 12 patients; extraarticular counts never exceeded 4% of the intraarticular counts. Chromosome aberrations were found not to be increased after treatment in the seven patients in whom adequate analysis could be done.

[Hemarthrosis of articular chondrocalcinosis. Apropos of 28 cases. Importance of treatment by isotopic synoviorthesis]

32 cases of hemarthrosis observed in 26 patients suffering from articular chondrocalcinosis are used as a basis for a review of the principal clinical anc paraclinical findings. Special mention is made of the fact that hemarthrosis occurs in the shoulder much less rarely than has been classically reported. The diagnostic value of finding microcristals of calcium pyrophosphate in hemorrhagic fluid is also emphasized. In addition to standard treatment, isotopic synoviortheses is shown to be effective for treatment of recurrent hemarthrosis. After an average of 3.3 years of follow-up, this treatment, although lacking certain analgesic effect, frequently leads to lasting cessation of the hemarthrosis, more often it seems, in the shoulder than in the knee.

Radiosynoviorthesis in haemophilic joint disease

The effects of radiosynoviorthesis on chronic haemophilic arthropathic joints were studied in six patients with severe haemophilia by a follow up study which spanned two and a half years. On clinical grounds the treatment was successful because pain and bleeding frequency diminished, although radiographic examination showed further deterioration of the treated joint. Chromosome damage was not detected. We conclude that radiosynoviorthesis is apparently changing the bleeding pattern of articular tissues without arresting the destruction and deformation of joints.

Chromosomal study after radioactive synoviorthesis for haemophilic haemarthrosis

Twenty joints in 19 haemophiliacs were treated by radioactive synoviorthesis with gold (Au 198) to prevent recurrent haemarthrosis. Twelve knees, six elbows and two ankles were treated in two separate groups (29. 9. 76 and 9. 5. 77). In eight cases (40%) no further haemarthrosis occurred. A diminution of bleeding was obtained in nine cases (45%), a total of 85% good results with 15% failures. One failure in the first group (an elbow) had a second synoviorthesis and was included in the second group also. Prior to synoviorthesis the joint was scanned with technetium (Tc99m) to compare the inflammation of the synovium with that of six months later. The technique including the dosage of Tc99m, Au 198, and factor VIII cover is presented. A leucocyte culture was performed in 16 cases to study any chromosomal breakage, by banding and fluorescent techniques.

[Treatment of hemophilic arthropathies by medical synoviorthesis]

The effects of medical synoviorthesis were studied by the authors in the haemophiliac. The use of radioisotopes was limited in view of the young age of the patients but a good result was achieved for the 5 elbows treated and for the 4 knees (yttrium 90) the results were 2 good, 1 fair and 1 failure. Osmic acid was injected in 44 knees. The results were good and fair in 51% of 39 knees. The results can be improved by a second injection. Synoviorthesis should be kept for joints with very few destructions because of the danger of worsening the osteocartilaginous lesions, specially with osmic acid.